Microsoft word - health history emergency treatment form 2014

PRINT CHILD’S LAST, FIRST NAME _______________________________
Health History/Emergency Treatment Form
Week of Attendance ______________________
Point Reyes Summer Camp 2014
This form must be postmarked or faxed on or before April 4, 2014 (earlier submissions are encouraged)
Mail to: Health Form, Point Reyes Summer Camp Call 415-663-1200 x 306 to confirm fax was received. THIS FORM IS TO BE COMPLETED BY PARENT/GUARDIAN; NO DOCTOR’S APPOINTMENT IS NECESSARY.
If your child has a medical condition or takes prescribed medication, it is likely we will contact you prior to camp.
Any changes to the information contained herein must be provided upon arrival at camp.
Camper Name _______________________________________ Birth Date ___/___/___ Gender ___ Age at Camp _____
Street Address _____________________________________________ Home Phone ( ) ______________________ City, State, Zip _____________________________________________________________________________________ School ______________________________________________________________________ Grade in fall 2014 ______ POINT REYES SUMMER CAMP REQUIRES A MINIMUM OF THREE EMERGENCY CONTACTS
1. Custodial Parent or Guardian ________________________________________________________________________ Day phone ( ) _________________ Night phone ( ) ___________________Cell ( ) __________________ 2. Second Parent or Guardian or Local Relative or Close Family Friend ________________________________________ Day phone ( ) _________________ Night phone ( ) ___________________Cell ( ) __________________ 3. Local Relative or Close Family Friend ________________________________________________________________ Day phone ( ) _________________ Night phone ( ) ___________________Cell ( ) __________________ 4. Local Relative or Close Family Friend ________________________________________________________________ Day phone ( ) _________________ Night phone ( ) ___________________Cell ( ) __________________ Insurance Carrier & Physician Information: Is the participant covered by medical insurance?
Insurance Carrier or Plan Name _______________________________________ Group # _________________________ Family Physician ________________________________________________ Phone ( ) ______________________ Required Parent/Guardian Authorization I certify that this health history is correct and complete. I authorize that my child named
herein has my permission to engage in all camp activities except as noted. I, the undersigned parent/legal guardian, do hereby give
permission to the medical personnel selected by the Camp Director or designee to order x-rays, tests, and treatment; to release any
records necessary for treatment, referral, billing, or insurance purposes; and to provide or arrange any necessary related transportation
for my child. In the event that I cannot be reached in an emergency, I hereby give permission to the health care providers selected by
the Camp Director or designee to secure and administer treatment, including hospitalization, for my child. I give my permission for
this completed form to be photocopied for official camp purposes.
(REQUIRED) Signature of Parent/Guardian* __________________________________________ Date _____________
Printed Name of Parent/Guardian ______________________________________________________________________
I authorize the Camp Director or designee at Point Reyes Summer Camp to administer (please check boxes) Tylenol (or children’s Tylenol, when appropriate)
Benadryl (or children’s Benadryl, when appropriate
in the appropriate dosage for my child’s age and weight, when deemed necessary for my child’s health and well-being. Signature of Parent/Guardian ________________________________________________________ Date _____________ Printed Name of Parent/Guardian ______________________________________________________________________ Cabin Assignment (PRSC permits only one friend request per child.)
My child would like to be placed in the same cabin with __________________________________________________
To reduce cliques and encourage openness, PRSC does not place groups of 4 or more friends in the same cabin.
Comfort Level at Camp
My child has been overnight away from home ______ nights. Please describe: ___________________________________
My child has a tendency to experience homesickness □ yes □ no □ not sure
PRINT CHILD’S LAST, FIRST NAME _______________________________
MEDICATIONS
Point Reyes Summer Camp staff is permitted to administer only those medications, including prescription and over-the-
counter medications, vitamins, supplements, medicated creams and/or lotions, with current labels attached and contained
in original packaging. We are legally bound to administer prescriptions and dosages exactly as written.
Please list all medications including prescription and over-the-counter medications, vitamins, supplements,
medicated creams and/or lotions you would like us to administer to your child during camp.
My child will be taking NO medication(s) while at camp. My child will be taking the following medication(s) at camp: Med #1 ___________________________ Dosage ___________ Reason _______________________________________
Specific Dosage & Time _____________________________________________________________________________
Med #2 ___________________________ Dosage ___________ Reason _______________________________________
Specific Dosage & Time _____________________________________________________________________________
Med #3 ___________________________ Dosage ___________ Reason _______________________________________
Specific Dosage & Time _____________________________________________________________________________
HEALTH HISTORY circle yes or no Please add additional pages, if necessary.
Yes No Anaphylactic Reaction (life-threatening allergic reaction to insect sting, food, chemical, etc)
Children diagnosed with severe allergic reaction/anaphylaxis must bring 2 allergic reaction kits (Epipen & Benadryl).
Trigger, date and severity of last reaction _____________________________________________________________ Check here if your child has been prescribed with and will be bringing 2 allergic reaction kits (Epipen & Benadryl). Yes No Asthma
Trigger(s) and date of last attack ___________________________________________________________________
Check here if your child has been prescribed with and will be bringing 2 asthma rescue inhalers. Yes No Heart Condition Details ____________________________________________________________________
Yes No Diabetes Details ___________________________________________________________________________
Yes No Epilepsy Date and severity of last episode ______________________________________________________
Yes No Frequent Severe Headaches, Nose Bleeds, Vomiting or Fainting

Date and severity of last episode ____________________________________________________________________ Yes No Difficulties with any of the following: □ Mobility □ Speech □ Hearing □ Vision □ Bedwetting
Details _________________________________________________________________________________________ _______________________________________________________________________________________________ ALLERGIES List all known.
Allergen
Describe reaction and management of reaction. __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Year of most recent tetanus shot __________________ Activity Limitations
Describe any activity restriction(s) your child will require ___________________________________________________
__________________________________________________________________________________________________
Dietary Restrictions
My child is not permitted to eat
Details ____________________________________________________________________________________________ My child is a picky eater. Details ____________________________________________________________________ Please provide any additional information about your child’s overall physical, emotional and/or behavioral tendencies that would assist us in caring for him/her ____________________________________________________________________ __________________________________________________________________________________________________ ADVENTURE CAMP I & II ONLY (ages 12-16)
Gear Request: My child would like to borrow:
NOTE: Scholarship recipients are given priority; we will contact you if we are NOT able to provide the gear you request.

Source: http://s375494505.onlinehome.us/sites/default/files/PRSC%20Health%20History%20Emergency%20Treatment%20Form%202014.pdf